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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT -EXPIRES -1 YEAR FROM DATE 1$SPRO <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coatpliance with San uin ount Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. -( � 7_31P 7-. /9 <br /> - <br /> N 7a _ ' P �i <br /> 1�j �f t Size/Acre e <br /> Job Address rV 'Y � City �y Anwv�A- <br /> Owner's Namemm"T � - Addressk �` i� Phone <br /> Contractor Address License No. Phone �/ �zz <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT"n =g DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ <br /> �` DISPOSAL FLD. r� ROP. LINE <br /> T NEAREST: SEPTIC TANK SEWER LINES 0 S <br /> DISTANCE 0 <br /> --- _p� -�.. g f <br /> �" �T � '- � PITS/SUMPS �v <br /> FOUNDATION _— AGRICULTURE WELL _GJL__ OTHER"WELL��Q - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private AbravelPack 0 Tracy Type of Casing_ Specilicationa <br /> Delta Depth of Grout Seat Type of Grout <br /> Il Public .1 Other n Oe p Ly <br /> I l Irrigation ✓0 44VApprox. Depth I I Eastern acs Seul Installed by 1— <br /> Repair Work Done U Type of Pump H.P. State Work Done p <br /> Sealing Material Depth <br /> Well Destruction ❑ Well Diameter ti 1. <br />{ <br /> Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ! I REPAIRlADDITION f I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence.___,_ Commercial— Other � <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments, <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines ' Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size ' Number <br /> ' SUMPS LI Distance to riesrest: Well Foundation °' Property Line <br /> DISPOSAL PONDS ❑ y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatiorn of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> j employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Calif <br /> The applican . or` I requ' s tions. Complete drawing on rev r�/i�aidee.�. <br /> i Title: tle � �— Dais: ` G <br /> t Signed <br /> FOR DEPARTMENT USE ONLY G ` <br /> Application Accepted by Kzal Date �'" 67� _ ._ Area <br /> y <br /> ' <br /> Pit or Grout Inspection by r Date `L,F-_ Final Inspection by <br /> Date <br /> - 'Addhi6hal Comments: <br /> Applicant - Return all copies to:- San Joaquin County Public Health Services <br /> 'Environmental Health Permit/Services <br /> -445 N' San Joaquin, PCO 96x 2009x, Stkn, rA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> l EM•13-24 iREV.,%It S) -, . .- ata s 11 <br /> -• EN 14-76 <br />